Page 273 - Critical Care Nursing Demystified

258 CRITICAL CARE NURSING DeMYSTIFIED

Nursing Diagnoses Patient Outcomes Implementations Evaluation
2 and 6 Level of con- Assess patient Determine
Ineffective cere- sciousness will responses to exter- effectiveness of
bral perfusion return to status nal stimuli, ques- planned out-
of alert and tions, and comes and
aware. commands. interventions
Ability to respond Perform Glasgow frequently
verbally and Coma Scale q 15 throughout each
appropriately to minutes. shift.
questions and Assess hypertensive
obey commands status and Cush-
will improve. ingʼs triad.
Patient will suffer Provide medications
no ill effects of as ordered.
ICP.
Maintain adequate
fluid and electrolyte
balance.
Potential for Gas exchange Promote adequate Determine
impaired gas will remain within gas exchange. effectiveness of
exchange related normal limits. Maintain effective O planned out-
to hypoventilation and CO levels. Pro- 2 comes and
2
(to correspond vide oxygenation of interventions Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
with Learning 2L/min. frequently
Objectives 1 throughout each
and 4) Assess status of shift.
lung sounds for
signs of aspiration
and fluid accumula-
tion.
Monitor arterial blood
gas results.
Maintain a patent
airway through posi-
tion changes and
suctioning as
needed.